Comparison of Transthoracic and Transhiatal Surgical Strategies for Esophageal Cancer: A Survival Analysis Open Access

Fernandez, Felix (2014)

Permanent URL: https://etd.library.emory.edu/concern/etds/jh343s80n?locale=en
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Abstract

Introduction: The optimal surgical approach for resection of esophageal cancer, transthoracic (TT) or transhiatal (TH), remains unknown despite extensive study. The goal of this study was to compare short term mortality and long term survival based on operative approach for resection of esophageal cancer resections.

Methods: We performed a retrospective cohort analysis using Surveillance, Epidemiology, and End Results (SEER) - Medicare linked data from 2002-2009. Patient and tumor and characteristics and survival were determined with SEER data. Medicare claims data were used to determine surgical approach, medical comorbidities, administration of chemotherapy and radiation, and healthcare resource use. Logistic regression analysis was used to examine the association of operative approach with operative mortality. A Cox proportional hazards model was utilized to examine the association between operative approach and long term survival.

Results: 918 TT and 653 TH resections were identified. Patients in the TT and TH groups had the following characteristics: age (72.8 vs. 73.4 yrs., p=0.02), gender (80.1% vs. 79.2% male, p=0.66) and distribution of comorbidity scores (Charlson score of 0: 60.2% vs. 62.3%, p=0.67). There were similar proportions of adenocarcinomas (TT 71.4% vs TH 72.9%, p=0.66) located in the lower esophagus (TT 72.1% vs TH 73.5%, p<0.12). Administration of induction therapy (chemotherapy and/or radiation) was similar between groups (TT 39.3% vs. TH 37.7%, p=0.51). More lymph nodes were evaluated with TT approaches (TT 15.2 vs. TH 11.3, p<0.001). Operative mortality was no different between groups (OR for TH 1.06, 95% CI 0.73-1.53). Overall long term survival was also no different between the TT and TH groups (HR for TH 0.99, 95% CI 0.82-1.20).

Conclusions: In an adjusted analysis in Medicare patients, TT and TH approaches to esophagectomy for esophageal cancer were associated with similar operative mortality and long-term survival. Operative approach is not a predictor of survival following surgical resection of esophageal cancer. Based on these data, thoracic surgeons should select the operative approach with which they are most proficient. Future investigations should incorporate financial and patient reported outcomes to allow a true value based comparison of TT and TH surgical approaches to esophageal cancer.

Table of Contents

Introduction .………………………………………………………………………… 1

Background ..………………………………………………………………………… 4

Specific Aims and Hypotheses ……………………………………………………… 7

Methods………………………………………………………………………………. 8

Data sources …………………………………………………………………... 8

Patients………………………………………………………………………… 8

Outcome measures…………………………………………………………….. 10

Statistical analysis …………………………………………………………..... 11

Power analysis………………………………………………………………… 13

Results………………………………………………………………………………… 13

Patient characteristics………………………………………………………….. 13

Perioperative outcomes………………………………………………………… 13

Long-term survival…………………................................................................. 14

Discussion …………………………………………………………………………… 17

Limitations……………………......................................................................... 20

Strengths ………............................................................................................... 21

Future directions………................................................................................... 21

References …………………………………………………………………………… 24

Tables………………………………………………………………………………… 30

Table 1

Medicare billing codes used to determine surgical approach and administration of chemotherapy and radiation

30

Table 2

Power calculations for operative mortality

31

Table 3

Power calculations for long term overall survival

32

Table 4

Clinical characteristics of patients undergoing esophagectomy

33

Table 5

Perioperative outcomes of patients undergoing esophagectomy

35

Table 6

Logistic regression model examining the association between the exposure, surgical approach, and outcome, operative mortality

36

Table 7

Linear regression model examining the association between the exposure, surgical approach, and the outcome, hospital length of stay

38

Table 8

Logistic regression model examining the association between the exposure, surgical approach, and the outcome, hospital readmission 30 days after discharge

40

Table 9

Cox proportional hazards model examining the association between the exposure, surgical approach, and the outcome, instantaneous risk of mortality

42

Table 10

Cox proportional hazards model examining the association between the exposure, surgical approach, and the outcome, instantaneous risk of cancer specific mortality

44

Figures………………………………………………………………………………... 46

Figure 1

Unadjusted Kaplan-Meier overall survival, transthoracic versus transhiatal esophagectomy

46

Figure 2

Unadjusted Kaplan-Meier cancer specific survival, transthoracic versus transhiatal esophagectomy

47

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